In a retrospective cohort study reported as a research letter in JAMA Oncology, Matsuo et al found an increasing use of minimally invasive surgery (MIS), an association of MIS with intraoperative capsule rupture, and an association of capsule rupture with poorer survival in patients with early ovarian cancer.
Study Details
The study used National Cancer Database data from patients with unilateral stage IA or IC1 ovarian cancer who underwent upfront surgery from 2018 to 2023. Associations between surgical modality, intraoperative capsule rupture, and overall survival were assessed in propensity score inverse probability of treatment weighting cohorts.
Key Findings
Among 11,425 patients included in the analysis, 5,770 (50.5%) underwent MIS; these included 2,930 (25.6%) undergoing conventional laparoscopic surgery and 2,840 (24.9%) undergoing robotic-assisted surgery.
From 2018 to 2023, the use of MIS increased from 45.1% to 57.1% (26.6% relative increase). The increase was primarily attributable to greater use of robotic-assisted surgery, which increased from 17.9% to 31.9% (78.2% relative increase; annual percentage change = 12.3%, 95% CI = 9.4%–15.9%).
In the propensity score–weighted cohort, the rate of intraoperative capsule rupture was higher with MIS vs open surgery (21.9% vs 19.4%; incidence rate ratio = 1.17, 95% CI = 1.07–1.27). Patients who underwent MIS who had intraoperative capsule rupture had poorer overall survival vs those who did not experience capsule rupture, with 3.5-year rates of 92.6% vs 94.7% (adjusted hazard ratio [HR] = 1.52, 95% CI = 1.13–2.06). Among patients who underwent open surgery, overall survival was nonsignificantly poorer for those with vs without capsule rupture, with 3.5-year rates of 91.0% vs 92.5% (adjusted HR = 1.30, 95% CI = 0.94–1.79).
The investigators concluded: “In this cohort study, MIS was increasingly incorporated in the management of early ovarian cancer in the US, with a majority of patients undergoing MIS by the early 2020s. MIS was associated with capsule rupture during ovarian cancer surgery. Intraoperative capsule rupture was associated with decreased overall survival, and this association may be larger during MIS compared to open surgery. Possible explanations of the difference, requiring further investigation, include (1) more tumor spills to the upper abdomen in Trendelenburg position without a packing barrier, (2) direct tumor contact and port-site tumor exposure, and (3) pneumoperitoneum with carbon dioxide gas that may provoke intra-abdominal tumor spread and seeding.”
Koji Matsuo, MD, PhD, of Division of Gynecologic Oncology, University of Southern California, Los Angeles, is the corresponding author for the JAMA Oncology article.
DISCLOSURE: The study was supported by the Ensign Endowment for Gynecologic Cancer Research. For full disclosures of the study authors, visit jamanetwork.com.
